Tracheoinnominate Artery Fistula

Audience This simulation provides training for emergency medicine residents in the stepwise management of a patient who presents with bleeding from a tracheoinnominate artery fistula. Additional learners who might benefit from this simulation are otolaryngology and general surgery residents as well as critical care fellows. Introduction Hemorrhage from a tracheoinnominate artery fistula (TIAF) is a rare but life-threatening complication in a patient with a recent tracheostomy. This complication occurs in 0.7% of tracheostomy patients with a mortality of 50–70%.1 Seventy-five percent of patients with a TIAF will present within the first three weeks of surgery and 50% of patients will present with a sentinel bleed that briefly resolves.1 Key elements of a history and exam that should raise a provider’s concern for this diagnosis include a recent tracheostomy (within the last 4 weeks), a percutaneous tracheostomy, prior radiation, chronic steroid use, a neck or chest deformity or a sentinel bleed.2 Survival from a TIAF hinges upon emergent, operative repair by an otolaryngologist and cardiothoracic surgeon. Cuff hyperinflation and the Utley Maneuver are critical bedside interventions to temporize this massive bleed and stabilize the patient for definitive, operative repair. Educational Objectives By the end of this simulation, learners will be able to: 1) perform a focused history and physical exam on any patient who presents with bleeding from the tracheostomy site, 2) describe the differential diagnosis of bleeding from a tracheostomy site, including a TIAF, 3) demonstrate the stepwise management of bleeding from a suspected TIAF, including cuff hyperinflation and the Utley Maneuver, 4) verify that definitive airway control via endotracheal intubation is only feasible in the tracheostomy patient when it is clear, upon history and exam, that the patient can be intubated from above, 5) demonstrate additional critical actions in the management of a patient with a TIAF, including early consultation with otolaryngology and cardiothoracic surgery as well as emergent blood transfusion and activation of a massive transfusion protocol. Educational Methods This case was written with a modified, low-fidelity manikin, traditionally used for training in nasogastric tube placement and tracheostomy care. We modified this manikin to simulate a hemorrhage from the tracheostomy site.3 The patient in our case had a history of laryngeal cancer, and thus we occluded his larynx for this simulation. As a result of this obstruction, he was unable to be intubated from above. We provided confederates, a bedside nurse and family member, to assist the learners throughout the case. We also utilized a simulation technician to operate dynamic vital signs on a simulated cardiac monitor. It would be technically challenging to adapt this case to a high-fidelity simulator due to potential for damage of the internal electrical elements by the large amount of artificial blood from the tracheostomy tube. However, a mechanical pump provided a useful means of active bleeding in this low-fidelity manikin. Research Methods We provided a pre- and post-simulation questionnaire for the 33 emergency medicine residents who participated in this simulation. There were 11 residents from each of the PGY-1, PGY-2 and PGY-3 year-groups. Thirty-two residents (97%) completed the pre-survey and 33 residents (100%) completed the post-survey. For our questions, we used a 5-point Likert Scale to assess a resident’s knowledge of the learning objectives within this simulation. Results Responses from our pre- and post- survey indicated a significant improvement in knowledge about a tracheoinnominate artery fistula as well as the general management of tracheostomy complications in the emergency department. Discussion This simulation is a useful educational tool for instructing emergency medicine residents on optimal management of tracheostomy emergencies such as a TIAF. The interprofessional teaching by an emergency medicine attending and mid-level (PGY-3) otolaryngology resident allowed for a richer and more detailed discussion during the debriefing. Throughout the case, the emergency medicine attending played the role of a bedside nurse and offered supportive, clinical cues when bleeding recurred. The otolaryngology resident played the role of a family member and offered helpful cues during the history and exam portion of the case. Following the case, both content experts provided useful clinical insight during the debriefing. If staffing availability permits, it might be advantageous to use additional simulation-trained personnel to play the roles of the nurse and family member, thus allowing the emergency medicine attending and otolaryngology content experts to simply view the case from the control room and perform the debriefing. Topics Tracheostomy, surgical airway, tracheoinnominate artery fistula, bleeding from tracheostomy site, complications with tracheostomies, hemorrhagic shock.

Linked objectives and methods: Emergency medicine providers commonly evaluate patients with complications from their tracheostomy. Most of these patients remain stable and are ultimately discharged from the emergency department. A tracheoinnominate artery fistula (TIAF) represents a rare but life-threatening complication from a tracheostomy procedure, usually within the first month. Other emergent complications from a tracheostomy are an acute obstruction, site infection or displacement of the tube. For this reason, the provider must rapidly perform a focused history and exam on any patient who presents with bleeding or other complications from a tracheostomy site (objective 1). When the patient in this simulation reports "½ cup" of bleeding from the tracheostomy tube, the evaluating providers needs to maintain an accurate differential diagnosis of bleeding from a tracheostomy site (objective 2). They should be particularly concerned about a TIAF, given that the tracheostomy is only 2 weeks old. After completion of a thorough history and physical exam, the simulation operator produces a series of coughs through the overhead speaker. This will cue the nurse at the bedside to discreetly activate the arterial pump, and the patient will begin to hemorrhage from the tracheostomy. At this point in the case, the providers must rapidly act to stop the bleed (objective 3). They must replace the uncuffed tracheostomy tube with a cuffed tracheostomy or endotracheal tube and hyperinflate the cuff. Bleeding temporarily stops but when it restarts, they must slowly pull back the tube and exert anterior pressure on the trachea. Again, bleeding will temporarily stop but when it restarts, the provider must demonstrate the Utley Maneuver. To perform this maneuver, the provider must deflate the cuff, place a gloved finger in the stoma and apply direct pressure between the bleeding vessel and posterior superior sternal wall. If providers are unable to fit their finger in the stoma with the cuffed tube, they may replace the cuffed tube with a smaller, uncuffed tube and reattempt the Utley Maneuver. The provider must demonstrate knowledge of each of these steps if bleeding recurs prior to surgical repair. Recurrent bleeding from the tracheostomy in this case portends a potentially failed airway, and the provider must only consider intubation from above if a thorough history and exam has deemed this a feasible endeavor (objective 4). In the case of this patient, his laryngeal cancer history made him an unsafe candidate for a traditional intubation attempt. This is a critical piece of any history for a patient who presents with potential airway compromise at the tracheostomy site. Rapid and early mobilization of otolaryngology, cardiothoracic surgery and the operating room team is imperative in this case. It is reasonable for the provider to consult with a specialist for any amount of bleeding greater than 10mL from the tracheostomy tube. 4 Due to repeated hemorrhage, despite multiple bedside maneuvers, transfusion of emergent-release blood and activation of a massive transfusion protocol are additional, life-saving maneuvers as this patient is transferred to the operating room (objective 5). Inattention to any of these objectives might be

Results and tips for successful implementation:
We offered this simulation to emergency medicine residents in small groups with 5 to 6 learners per group. Members of each group went through the entire case together. A more ideal number of participants might be 1 or 2 residents per group, to offer each participant a more hands-on experience. We had a simulated patient monitor, and a simulation operator made dynamic changes to the monitor during the case. We had an emergency medicine (EM) attending who played the role of the emergency department nurse and a mid-level, otolaryngology (ENT) resident who played the role of the patient's family member during the case. This latter role is very helpful to boost the fidelity of the case because patients with tracheostomy tubes often have limited or no phonation and an additional historian is commonly needed. The ED nurse gave the learners a brief triage history upon starting the case, and then the learners assumed full management of the patient.
The EM attending and ENT resident performed a bedside debriefing after the case. One benefit of a bedside debriefing was the hands-on access to the manikin and supplies to directly review any critical steps that were missed during the simulation. We allowed 40 minutes per group for the entire simulation but would allot an entire hour for this exercise in the future. This case raised many thoughtful questions regarding management of a tracheoinnominate artery fistula and general tracheostomy care in the ED; ample time should be allowed for this discussion during the debrief. Review of tracheostomy equipment such as cuffed and uncuffed devices, their endotracheal tube counterparts, basic tracheal suctioning, and best ways to both oxygenate and ventilate a tracheostomy patient are better reviewed on the manikin during a bedside debriefing. We provided a 3D anatomic model of the brachiocephalic trunk, in scaled proximity to cardiac and pulmonary structures, to reinforce the pathophysiology of a TIAF. We also highly recommend having both an emergency medicine and otolaryngology content expert as co-facilitators for this case. As an interdisciplinary offering, both perspectives are extremely helpful during the debriefing. To avoid the possibility of revealing the case, we did not provide any prereading to learners before this case. In retrospect, this would have greatly reinforced the learning during and after this case. Along similar lines, a post-simulation reading list would be a helpful resource for additional review.
Our pre-and post-survey results revealed that the emergency medicine residents who completed this simulation significantly improved their knowledge in the management of this rare but life-threatening condition. When asked about their familiarity with the Utley Maneuver, 28% of residents (9/32) responded "agree" or "strongly agree" before the simulation, and 91% (30/33) of residents responded "agree" or "strongly agree" after the simulation. When asked about their knowledge of additional methods to curb bleeding from a tracheostomy site, 25% of residents (8/32) responded "agree" or "strongly agree" before the simulation, while 94% of residents (31/33) responded "agree" or "strongly agree" after the simulation. When asked about baseline knowledge of a differential diagnosis of bleeding from a tracheostomy site, 22% of residents (7/32) responded "agree" or "strongly agree" before the simulation, and 94% of residents (31/33) responded "agree" or "strongly agree" after the simulation. Responses from our pre-and post-survey indicated a significant improvement in knowledge about tracheoinnominate artery fistula as well as general management of tracheostomy complications in the emergency department.

Case Description & Diagnosis (short synopsis):
A patient with a recent tracheostomy presents to the emergency department (ED) with a sentinel bleed from his tracheostomy tube. The bleeding has initially stopped but the patient subsequently has a massive hemorrhage from the tracheostomy tube after a brief coughing spell. The provider must recognize a tracheoinnominate artery fistula (TIAF) as the likely cause of this hemorrhage and perform stepwise maneuvers to stop the bleed. In addition to hemorrhage control, the provider must consult emergently with otolaryngology, cardiothoracic surgery, and the operative team.

Equipment or Props Needed:
-Personal Protective Equipment (gown, gloves, eye, and face protection) -Low-fidelity nasogastric/tracheostomy task trainer, modified with arterial line pump and tubing: The arterial line pump sits on a mayo stand beside the patient and nurse; the pump and blood reservoir are discreetly covered with a sheet. The arterial line tubing connects to the patient underneath the gown. 3 -Simulated patient monitor with dynamic vital signs (heart rate, respiratory rate, blood pressure, pulse oximetry) -Bougie or another airway exchange catheter -Bedside suction canister with tubing and tracheal suction catheter -10 cc syringe for inflation/deflation of cuff -Crash cart with defibrillator -Airway cart (including size 5 and 6 cuffed tracheostomy tubes, 4-0 and 5-0 cuffed and uncuffed endotracheal tubes, ambu bag, nonrebreather) -2 units of artificial blood and container with additional blood products for massive transfusion protocol Confederates needed: -Assistant to play nurse at bedside -Assistant to play family member who provides additional history during the case (this role could be played as voice-over by the simulation operator) -Simulation Operator to provide "coughing" sounds of patient when bleeding recurs as well as operation of dynamic vital signs on the simulated monitor

Stimulus Inventory:
None (nurse may state that x-ray is "pending" as patient is stabilized for the operating room)

Background and brief information:
The patient presents to a large, academic emergency department with his family member. He reports a moderate amount of bleeding from his tracheostomy tube that he describes as approximately ½ cup in volume. His vitals are stable and bleeding has resolved but there is a visible stain of blood on his shirt from the recent bleed.

Initial presentation:
The patient initially presents with stable vital signs and history of a recent bleed from his tracheostomy site that has since resolved. A family member is present at the bedside to provide the history.
How the scene unfolds: The patient has a history of recurrent laryngeal cancer and a remote history of chemotherapy and radiation treatments. He received a percutaneous, awake tracheostomy 2 weeks ago by an otolaryngologist at the presenting hospital. This was done after he was found to have recurrence of the laryngeal cancer with worsening upper airway obstruction. The patient's family member is present at the bedside to provide this critical history to the provider. Upon further questioning, the family member denies that the patient has experienced any recent illness or complications until the bleeding episode this morning. They report approximately "½ cup" of blood from the tracheostomy tube that has resolved. He does not take aspirin or other blood thinners. He denies any recent fever or other illness. He denies any difficulty breathing and appears quite comfortable and alert on initial assessment. If asked, the family member adds that the patient's cancer was blocking his upper airway and he had the tracheostomy performed to breathe better (this cues the learner that the patient is unlikely able to be intubated from above). If the learner consults with the medical record or calls the patient's otolaryngologist, they will discover the same information. 5. If rebleed occurs, gently pull back the tube and exert anterior pressure on the trachea. 6. If rebleed occurs, deflate the cuff and perform the Utley Maneuver. The providers who perform this maneuver must not move their finger until the patient is in the operating room and under the care of the surgical team. If the providers are unable to fit their finger in the stoma, they may reattempt after replacement of the cuffed with an uncuffed tube that is one size smaller. 7. When the patient becomes hemodynamically unstable from recurrent bleeding, the provider must order two units of emergent-release blood and activate a massive transfusion protocol. Nurse may ask if it is ok to put him back in the waiting room until a bed becomes available. Due to concern for a sentinel bleed from a TIAF this would be unsafe, and the provider should immediately try and get him into an exam room.

Monitor display (vital signs)
Learner should voice concern for a TIAF and consult emergently with ENT, CT, Surgery and the OR Team for definitive repair.
If learner does not consult early with specialties, the family member states that his otolaryngologist was very concerned and asked to be called immediately upon arrival to the ED, prompting a consultation for next steps.

8:00
Bleeding briefly stops with placement of a hyperinflated, cuffed tube. Several minutes later, the bleeding restarts.
Patient appears more anxious.
Nurse informs the provider that the OR team is on the way.
Provider must slowly withdraw the tube while exerting pressure against the anterior trachea. This maneuver will stop the bleeding again.
If this maneuver is not performed, then bleeding continues. The ENT consultant may call for a status update and instructs learner on placement of a hyperinflated, cuffed tube, anterior tracheal pressure and the Utley Maneuver, if refractory bleeding, to stabilize before the OR.

Pearls:
1. This patient appears stable with a recent, sentinel bleed from his tracheostomy site. The learner needs to appreciate that his recent tracheostomy placement makes him higher risk for a tracheoinnominate artery fistula (TIAF). Risk for this complication is highest within the initial four weeks of this procedure. 2. Rule-out a possible bleeding diathesis during a history of the medications. Emergent reversal agents should be considered if the patient is on coumadin or other blood thinners. 3. Early placement of patient, while stable, on a cardiac monitor with pulse oximetry. Early placement of 2 large-bore peripheral IVs in anticipation of potential for deterioration. 4. The learner should attempt early to determine, via ENT consult, review of the operative notes and/or patient history, if the patient can be intubated from above. The learner must also closely monitor the patient's hemodynamic status due to the potential for serious rebleed upon presentation with a sentinel bleed from a TIAF. 5. Upon consultation with an otolaryngologist and/or cardiothoracic surgeon, in the absence of a rebleed, the provider might consider CT Angiography for more detailed assessment of a possible TIAF. This should only be considered in a stable patient without active bleeding. 6. The learner demonstrates a stepwise approach to hemorrhage from the tracheostomy tube, including placement of a cuffed tube with hyperinflation of the cuff. For continued bleeding, this is followed by a slow withdrawal of the hyper-inflated, cuffed tube, with anterior pressure on the trachea. If bleeding persists, perform the Utley Maneuver (place a gloved finger in the tracheostomy site and exert pressure between the bleeding vessel and the posterior surface of the sternum). If the providers are unable to fit their finger in the ostomy, they may need to replace the cuffed tube with a smaller, uncuffed tube and reattempt. The provider must maintain the Utley Maneuver until definitive, operative repair by ENT and CT Surgery.

Other debriefing points:
We implemented several techniques within our case to prevent this patient from dying from hemorrhagic shock. The nurse and family member were able to provide helpful cues if the learner was struggling to control the airway or bleeding. For example, if the learner attempted to intubate the patient from above, the family member might state that he was told this would never be possible because of the size of the cancer in the airway. The nurse might offer suggestions such as replacement of an uncuffed tube with a cuffed tube if the learner is struggling to stop the bleeding. The nurse may even suggest a blood transfusion and supplemental oxygen if the providers are not performing this. The ENT consultant, via phone, can also coach the provider on stepwise maneuvers to temporize bleeding. Prior to the simulation, the facilitators must decide if the confederates will aid the learner in ways that will prevent the patient from ongoing hemorrhage and/or death or whether the learner will act with complete autonomy, at the risk of a potentially fatal outcome. As a group, we decided to offer cues from either the nurse, family member or ENT consultant, to prevent the patient from exsanguinating from this bleed. If these confederates aid the provider, there must be a detailed discussion, in the debrief, on these missed, critical steps. An additional area of discussion for the debrief includes management of the crash and/or failed airway in one of these scenarios. The complex airway issues of this case may facilitate discussion about key airway teams (ENT, anesthesia and/or surgery) within the training institution and critical junctures when their services should be requested. During this debriefing we used a 3D anatomic model that included the heart, aortic arch and its branches as well as the trachea and esophagus. This visual aid helped us to review the pathophysiology of a TIAF as well as the mechanism of the Utley maneuver. Critical Actions: Perform a detailed history and exam of a patient who presents with bleeding from the tracheostomy site. This should include clarification of whether the patient can be intubated from above. Order one or two, large-bore peripheral IVs and bloodwork, including type and screen, complete blood count (CBC), basic metabolic panel (BMP) and coagulation panel.
When the rebleed occurs, apply gentle suction and replace the uncuffed tracheostomy tube with a cuffed tracheostomy tube (or cuffed endotracheal tube) of similar size and hyperinflate the cuff. Recognize this is likely a tracheoinnominate artery fistula and emergently consult with otolaryngology, cardiothoracic surgery and the operating room team. If rebleed occurs, gently pull back the tube and exert anterior pressure on the trachea. If rebleed occurs, deflate the cuff and perform the Utley Maneuver. The providers who perform this maneuver must not move their finger until the patient is in the operating room and under the care of the surgical team. If the providers are unable to fit their finger in the stoma, they may reattempt after replacement of the cuffed with an uncuffed tube that is one size smaller. When the patient becomes hemodynamically unstable from recurrent bleeding, the provider must order two units of emergent-release blood and activate a massive transfusion protocol.